Introduction

Despite improvements in the overall health of the US population, significant disparities still exist among many racial and ethnic groups. Efforts to address the multifactorial causes of these disparities are underway at many institutions, and efforts to promote diversity and inclusion are now core regulatory requirements for residency training programs. Three main pathways have emerged in the literature that illustrate how increasing diversity among physicians can aid in decreasing health disparities: (1) addressing physician practice choices that may lead to increased access to care; (2) increasing physician-patient communication and cultural competency; and (3) diversifying medical education.¹

In the 1990s, “3000 by 2000” was introduced as a national effort to increase the pipeline of underrepresented in medicine (UiM) physicians in the United States. Additional goals included increasing access to culturally competent physicians, increasing patient trust and satisfaction, and improving the minority patient-physician interaction.² Research has shown that minority patients are more likely to report satisfaction with care when their usual care physician is a UiM physician rather than a white physician. Such alignment in race/ethnicity, language, or other sociocultural factors is thought to enhance efficacious and culturally competent communication.³ In addition, many patients reported increased comfort with UiM physicians, which enhanced the patient-physician relationship.³ Moreover, UiM physicians were more likely to practice in communities with larger populations of UiM patients who may be uninsured and have an overall poorer health status compared with major ethnicities.⁴

In 2004, the Association of American Medical Colleges (AAMC) updated the definition of “underrepresented in medicine” as “racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.” With this updated definition, a targeted approach began to take shape as the US population comprised 30% UiM patients relative to a physician workforce that included less than 10% of physicians who identified as UiM.^5,6 The momentum to increase the number of UiM physicians created awareness of the shortage of UiM faculty available to cultivate supportive learning environments. In addition, there is a lack of adequate knowledge about the particular needs of UiM medical students and even less information on residents.⁶

Residency can be a challenging time for all trainees given the emotional and physical demand of the work environment; however, UiM residents are often among a small group of residents. One study reviewed data from the American Medical Association looking at withdrawal and extended leave during residency training from 1991 to 1992.⁷ While overall the percentage of residents who withdrew (2.7%) and those who took extended leave (1.0%) were low, when they did subgroup analysis they found that minority physicians were almost 30% more likely to withdraw from residency than their white counterparts and 8 times more likely to take extended leave of absence.^7,8 A study looking at attrition rate in US obstetrics and gynecology residency programs also found higher attrition rates in UiM residents.⁹ Osseo-Asare et al performed a qualitative study of 27 minority resident physicians representing 21 residency programs and a diverse range of specialties to better characterize the experience of race/ethnicity in the workplace.⁸ They found that in addition to the typical stress of residency training, participants reported a daily barrage of microaggressions, being tasked as race/ethnic ambassadors, and challenges negotiating professional and personal identity while seen as “other,” which affected their overall well-being.⁸ Research has shown that factors such as physician burnout, depression, job dissatisfaction, and low quality of life have been associated with negative effects on patient care and poor performance.¹⁰ Thus, it is imperative that these issues are addressed for UiM residents. Notably, as social and meeting structures have changed in the setting of the COVID-19 pandemic, and as the impact of this disease disproportionally affects communities of color, it is imperative for programs to find meaningful ways to support and engage UiM trainees.

The viewpoints of UiM faculty in one qualitative study addressed the need to improve the culture of diversity in academic medical centers by increasing the number of diverse leaders, thus mirroring the US population.¹¹ In 2018, only 3.6% of faculty at US academic medical schools were African American and only 5.5% were Hispanic, Latino, or of Spanish origin, an inadequate number to meet the projected target.¹² Orom et al described the necessity of transforming medicine into a more inclusive profession by improving the learning and social environment for students, given that at baseline UiM students were more likely to have negative racial and academic experiences compared with their counterparts.¹³ This has led to higher attrition of UiM medical students and may have downstream effects on recruitment of younger students into medical school, but also impact residency selection and desire to pursue a career in academic medicine in the future.¹³ Thus, in addition to better understanding the experience of UiM medical students, it is paramount that we better understand the experience of UiM residents during their residency training.

This study identifies specific experiences that have challenged and contributed to UiM residents' overall resiliency and well-being, so we can better inform successful programing for residency programs.

Methods

This is a qualitative descriptive study using a retrospective review of focus group transcripts of UiM internal medicine resident physicians.

Procedures

A faculty member who was not associated with the residency program leadership facilitated the focus groups. The questions were standardized and developed from the authors after an initial meeting to discuss the issues related to the study question. The questions discussed in each focus group are listed in Table 1. The focus group members agreed to taped interviews for data collection during the session. Data from all 5 institutions were compiled and sent to a central location for data interpretation.

Table 1 Focus Group Questions

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Results

Participants

A total of 5 academic residency programs were included in the study from January through June 2017: East Carolina University (Greenville, NC), Duke University (Durham, NC), Morehouse School of Medicine (Atlanta, GA), University of North Carolina (Chapel Hill, NC), and Wake Forest University (Winston-Salem, NC). Residents who identified themselves as UiM volunteered to participate in focus groups conducted. A participation rate was calculated for each residency program, with East Carolina 48%, Duke University 47%, Morehouse School of Medicine 69%, University of North Carolina 50%, and Wake Forest School of Medicine 75% (Table 2).

Table 2 Underrepresented in Medicine Resident Focus Group Participation Rates From Each Program

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Following the consensus-based review of the 5 transcripts, 25 distinct codes in 8 parent code categories were determined (Table 3). After thematic analysis by the research team of the 8 code categories, 25 distinct codes therein revealed 2 primary themes: resilience and isolation. Additionally, 3 secondary themes emerged, which serve as mediators for the primary themes. The secondary mediating themes were social support, mentorship, and external expectations or biases. Each theme and its mediators are described below. Moreover, representative individual resident responses from transcript review, exemplifying the primary and secondary themes, can be found in the Box.

Table 3 Code Categories From Focus Group Transcript Review

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The common themes identified in the focus groups were resilience and isolation, both of which may be influenced and affected positively or negatively by social support, mentorship, external expectations, and bias. In defining “diversity,” participants viewed diversity as a needed entity in medical education. Moreover, it was viewed broadly as diversity in gender, race, and religion, but also noted were subcultures and socioeconomic status within the UiM community, presence or absence of role models, as well as the need for exposure to diverse groups earlier on in the medical education process.

UiM residents generally had positive attitudes regarding their programs and teaching faculty. They cited that having supportive faculty was important and having an UiM faculty member who was able to empathize with them was paramount. Having a confidential safe haven from program leadership to express their unique experiences was welcomed during the sessions.

Discussion

The shared experiences of social isolation, facing prejudice, and the assumption that they are non-clinical support were all examples of how common experiences could either lead to greater resilience or further isolation, depending on the level of resilience of the trainee or support offered by the individual programs. The additional burdens uniquely faced by UiM residents during training may threaten their overall well-being, including being the target of racial slurs, assumptions that they are non-clinical support staff rather than part of the medical team, and assumptions that they are medically trained to serve as translators.

Moreover, UiM residents stated a bias from UiM non-medical peers or family regarding wealth or prestige as young physicians early in their stage of training. This can be challenging for some UiM residents who may be first generation physicians or have family members/peers unfamiliar with medical school debt and residency pay structures. In addition, some may feel guilt for being successful and not want others to view them as “superior” or “better than” family members or non-medical peers. This added familial and social/community pressure, prior to completion of their training, placed an additional burden to succeed.

It is not uncommon for a UiM resident who ultimately becomes or is resilient to have experienced isolation at some time in their medical career, specifically during residency.⁸ Further understanding the activities, mindset, and mentorship that influence these isolation experiences is paramount. The literature indicates that both individual-focused and organizational strategies can result in clinically meaningful reductions in burnout and dissatisfaction among physicians; however, more research is needed to establish which interventions are most effective in a specific population. Activities aimed to promote well-being include mentoring, volunteering, and mindfulness and reflection exercises.¹⁷

The critical threshold of mentoring experiences for UiM residents that would serve to overcome the experienced isolation, attract more UiM students into a residency, or serve as best practices to diminish the additional stress/fear of acceptance by patients is unknown. While the input from our UiM focus groups is consistent with other reports nationally regarding the UiM residency experience, there are limitations to this work. Despite being multi-institutional, our focus groups are still geographically limited to the Southeast United States. The experience of UiM residents in the Southeast compared to other regions of the United States warrants further investigation.

Additionally, the focus groups represent a relatively small sample size and brief time frame; they do not completely reflect the experiences, better and worse, of UiM residents over time. Furthermore, participation was voluntary on the part of residents. Lower participation rates of UiM may have been due to clinical responsibilities or those who feel more isolated, thus causing a selection bias.

The broad feasibility of this study allows for generalized implementation as it encourages embracing diversity and building a narrative for UiM residents to express their responses to unconscious bias and factors contributing to increased stress and burnout regardless of the region or specialty. This descriptive framework may aid in creating an environment facilitating UiM networks, mentoring, and coaching, which cultivates acceptance rather than isolation.

Given these findings among the UiM residents, a comprehensive approach to retention is suggested, including development of an early UiM local network followed by regular scheduled mentoring with faculty for social and cultural support while transitioning into new roles, and acknowledgement during coaching and advising sessions of the reality of isolation experienced by UiM residents.

Moreover, future efforts may also include the sharing of scripts to build a catalog of responses to unwanted prejudice or unconscious bias for use in US medical programs, career-specific UiM mentoring via either local faculty or a regional network and UiM resident-driven initiatives as a strategy to prevent burnout and promote well-being.

Within this comprehensive approach to understanding the UiM resident's unique needs, we have not only highlighted what is suggested to promote UiM resident retention, but have also recognized the inimitable resilience of the UiM resident and the potential for leadership within their respective current programs and beyond.

Conclusions

The common themes identified in the focus groups were resilience and isolation, both of which may be influenced and affected positively or negatively by social support, mentorship, external expectations, and bias.